Silver Absorption on Burns After the Application of Acticoat™: Data From Pediatric Patients and a Porcine Burn Model:

Safety of Silver Dressings in Infants; a Systematic Scoping Review

Silver-based dressings are used to reduce infection risk and optimize conditions for wound healing. They are widely used in the management of burns and other complex wounds. However, reports of elevated serum silver and concern over systemic toxicity have meant that their use in young children has been questioned. The aim of the current study was to map the literature relating to the use of silver-based dressings in children under 1 year of age. A systematic scoping review was conducted according to the methodology described by the Joanna Briggs Institute. Sources were identified from major medical databases as well as the gray literature. Inclusion criteria were the use of silver-based dressing in children under 1 year of age. Outcomes of interest were complications or adverse events attributed to silver-based dressings and elevated serum silver levels. A total of 599 sources were identified through the search strategy, with 110 included for review. Complications were described in 31 sources, with the most frequent being wound infection. No cases of argyria, kernicterus, or methemoglobinemia were reported. Six sources documented elevated serum silver levels in infants but none reported adverse events related to this. On the basis of current evidence, we suggest reserving silver dressings in infants under 1 for wounds that are at high risk of infection. Wound area and duration of treatment should be considered when assessing the risk of systemic absorption of silver. Standardized data collection and recording of complications and adverse events is recommended to better inform future clinical decision-making.

Mass-Spectrometry-Based Research of Cosmetic Ingredients

Cosmetic products are chemical substances or mixtures used on the skin, hair, nails, teeth, and the mucous membranes of the oral cavity, whose use is intended to clean, protect, correct body odor, perfume, keep in good condition, or change appearance. The analysis of cosmetic ingredients is often challenging because of their huge complexity and their adulteration. Among various analytical tools, mass spectrometry (MS) has been largely used for compound detection, ingredient screening, quality control, detection of product authenticity, and health risk evaluation. This work is focused on the MS applications in detecting and quantification of some common cosmetic ingredients, i.e., preservatives, dyes, heavy metals, allergens, and bioconjugates in various matrices (leave-on or rinse-off cosmetic products). As a global view, MS-based analysis of bioconjugates is a narrow field, and LC- and GC/GC×GC-MS are widely used for the investigation of preservatives, dyes, and fragrances, while inductively coupled plasma (ICP)-MS is ideal for comprehensive analysis of heavy metals. Ambient ionization approaches and advanced separation methods (i.e., convergence chromatography (UPC2)) coupled to MS have been proven to be an excellent choice for the analysis of scented allergens. At the same time, the current paper explores the challenges of MS-based analysis for cosmetic safety studies.

Cytotoxicity and concentration of silver ions released from dressings in the treatment of infected wounds: a systematic review

Introduction

Silver-releasing dressings are used in the treatment of infected wounds. Despite their widespread use, neither the amount of silver released nor the potential in vivo toxicity is known. The aim of this study was to evaluate the cytotoxic effects and the amount of silver released from commercially available dressings with infected wounds.

Methods

The review was conducted according to the PRISMA statement. The Web of Science, PubMed, Embase, Scopus, and CINAHL databases were searched for studies from 2002 through December 2022. The criteria were as follows: population (human patients with infected wounds); intervention (commercial dressings with clinical silver authorized for use in humans); and outcomes (concentrations of silver ions released into tissues and plasma). Any study based on silver-free dressings, experimental dressings, or dressings not for clinical use in humans should be excluded. According to the type of study, systematic reviews, experimental, quasi-experimental, and observational studies in English, Spanish, or Portuguese were considered. The quality of the selected studies was assessed using the JBI critical appraisal tools. Studies that assessed at least 65% of the included items were included. Data were extracted independently by two reviewers.

Results

740 articles were found and five were finally selected (all of them quasi-experimental). Heterogeneity was found in terms of study design, application of silver dressings, and methods of assessment, which limited the comparability between studies.

Conclusion

In vivo comparative studies of clinical dressings for control of infection lack a standardized methodology that allows observation of all the variables of silver performance at local and systemic levels, as well as evaluation of its cytotoxicity. It cannot be concluded whether the assessed concentrations of released silver in commercial dressings for the topical treatment of infected wounds are cytotoxic to skin cells.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022351041, PROSPERO [CRD42022351041].

Diverse Antibacterial Treatments beyond Antibiotics for Diabetic Foot Ulcer Therapy

Diabetic foot ulcer (DFU), a common complication of diabetes, has become a great burden to both patients and the society. The delayed wound closure of ulcer sites resulting from vascular damage and neutrophil dysfunction facilitates bacterial infection. Once drug resistance occurs or bacterial biofilm is formed, conventional therapy tends to fail and amputation is unavoidable. Therefore, effective antibacterial treatment beyond antibiotics is of utmost importance to accelerate the wound healing process and prevent amputation. Considering the complexity of multidrug resistance, biofilm formation, and special microenvironments (such as hyperglycemia, hypoxia, and abnormal pH value) at the infected site of DFU, several antibacterial agents and different mechanisms have been explored to achieve the desired outcome. The present review focuses on the recent progress of antibacterial treatments, including metal-based medications, natural and synthesized antimicrobial peptides, antibacterial polymers, and sensitizer-based therapy. This review provides a valuable reference for the innovation of antibacterial material design for DFU therapy.

Treatment of infection and inflammation associated with COVID-19, multi-drug resistant pneumonia and fungal sinusitis by nebulizing a nanosilver solution

Solutions containing Ag⁰ nanoclusters, Ag⁺¹, and higher oxidation state silver, generated from nanocrystalline silver dressings, were anti-inflammatory against porcine skin inflammation. The dressings have clinically-demonstrated broad-spectrum antimicrobial activity, suggesting application of nanosilver solutions in treating pulmonary infection. Nanosilver solutions were tested for antimicrobial efficacy; against HSV-1 and SARS-CoV-2; and nebulized in rats with acute pneumonia. Patients with pneumonia (ventilated), fungal sinusitis, burns plus COVID-19, and two non-hospitalized patients with COVID-19 received nebulized nanosilver solution. Nanosilver solutions demonstrated pH-dependent antimicrobial efficacy; reduced infection and inflammation without evidence of lung toxicity in the rat model; and inactivated HSV-1 and SARS-CoV-2. Pneumonia patients had rapidly reduced pulmonary symptoms, recovering pre-illness respiratory function. Fungal sinusitis-related inflammation decreased immediately with infection clearance within 21 days. Non-hospitalized patients with COVID-19 experienced rapid symptom remission. Nanosilver solutions, due to anti-inflammatory, antiviral, and antimicrobial activity, may be effective for treating respiratory inflammation and infections caused by viruses and/or microbes.

Cirrhotic Liver of Liver Transplant Recipients Accumulate Silver and Co-Accumulate Copper

Silver-based materials are widely used in clinical medicine. Furthermore, the usage of silver containing materials and devices is widely recommended and clinically approved. The impact on human health of the increasing use of silver nanoparticles in medical devices remains understudied, even though Ag-containing dressings are known to release silver into the bloodstream. In this study, we detected a widespread and sometimes significant silver accumulation both in healthy and sick liver biopsies, levels being statistically higher in patients with various hepatic pathologies. 28 healthy and 44 cirrhotic liver samples were investigated. The median amount of 0.049 ppm Ag in livers was measured in cirrhotic livers while the median was 0.0016 ppm for healthy livers (a more than 30-fold difference). The mean tissue concentrations of essential metals, Fe and Zn in cirrhotic livers did not differ substantially from healthy livers, while Cu was positively correlated with Ag. The serum levels of gamma-glutamyl transpeptidase (GGTP) was also positively correlated with Ag in cirrhotic livers. The increased Ag accumulation in cirrhotic livers could be a side effect of wide application of silver in clinical settings. As recent studies indicated a significant toxicity of silver nanoparticles for human cells, the above observation could be of high importance for the public health.

A human skin equivalent burn model to study the effect of a nanocrystalline silver dressing on wound healing

In this study, a deep burn wound model was established using a 3D human skin equivalent (HSE) model and this was compared to native skin. HSEs were constructed from dermis derived from abdominoplasty/breast surgery and this dermal template was seeded with primary keratinocytes and fibroblasts. The HSE model was structurally similar to native skin with a stratified and differentiated epidermis. A contact burn (60 °C, 80 °C, 90 °C) was applied with a modified soldering iron and wounds were observed at day 1 and 7 after burn. The HSEs demonstrated re-growth with keratinocyte proliferation and formation of a neo-epidermis after burn injury, whereas the ex vivo native skin did not. To assess the suitability of the 3D HSE model for penetration and toxicity studies, a nanocrystalline silver dressing was applied to the model for 7 days, with and without burn injury. The effect of silver on skin re-growth and its penetration and subcellular localization was assessed in HSEs histologically and with laser ablation-inductively coupled plasma mass spectrometry (LA-ICPMS). The silver treatment delayed or reduced skin re-growth, and silver particles were detected on the top of the epidermis, and within the papillary dermis. This novel in vitro 3D multicellular deep burn wound model is effective for studying the pathology and treatment of burn wound injury and is suitable for penetration and toxicity studies of wound healing treatments.

Advancements in Regenerative Strategies Through the Continuum of Burn Care

Burns are caused by several mechanisms including flame, scald, chemical, electrical, and ionizing and non-ionizing radiation. Approximately half a million burn cases are registered annually, of which 40 thousand patients are hospitalized and receive definitive treatment. Burn care is very resource intensive as the treatment regimens and length of hospitalization are substantial. Burn wounds are classified based on depth as superficial (first degree), partial-thickness (second degree), or full-thickness (third degree), which determines the treatment necessary for successful healing. The goal of burn wound care is to fully restore the barrier function of the tissue as quickly as possible while minimizing infection, scarring, and contracture. The aim of this review is to highlight how tissue engineering and regenerative medicine strategies are being used to address the unique challenges of burn wound healing and define the current gaps in care for both partial- and full-thickness burn injuries. This review will present the current standard of care (SOC) and provide information on various treatment options that have been tested pre-clinically or are currently in clinical trials. Due to the complexity of burn wound healing compared to other skin injuries, burn specific treatment regimens must be developed. Recently, tissue engineering and regenerative medicine strategies have been developed to improve skin regeneration that can restore normal skin physiology and limit adverse outcomes, such as infection, delayed re-epithelialization, and scarring. Our emphasis will be centered on how current clinical and pre-clinical research of pharmacological agents, biomaterials, and cellular-based therapies can be applied throughout the continuum of burn care by targeting the stages of wound healing: hemostasis, inflammation, cell proliferation, and matrix remodeling.

Blood and Tissue Silver Levels Following Application of Silver-Based Dressings to Sulfur Mustard Chemical Burns

Silver-based dressings are commonly used in burn care. Silver sulfadiazine use is associated with elevated blood, urine, and tissue levels of silver ion. We examined wound and tissue levels of silver ion in a two-species model of sulfur mustard chemical burn injury treated with two different silver-based dressings. Superficial dermal and moderate thickness dermal chemical burns were induced in 16 hairless guinea pigs and in 16 Gottingen minipigs by exposure to sulfur mustard vapor. After debridement, silver-nylon burn dressings or silver-calcium alginate dressings were applied and changed every 7 days until wound healing or a maximum of 60 days post exposure. At autopsy, liver, spleen, and wound samples were harvested. Silver ion was measured using inductively coupled plasma-mass spectrography with a lower level of detection of 0.02 parts per billion. Negligible silver ion levels were found in the liver (mean < 0.003 μg/g of tissue) and spleen (mean < 0.05 μg/g) of all 32 animals. Wound biopsies showed silver ion levels ranging from 0.07 to 19.5 μg/g of tissue. Wound levels were higher in minipigs than in hairless guinea pigs and were higher in animals treated with silver-nylon burn wound dressings than with silver-calcium alginate dressings. Silver ion could be detected in some wounds 40 days after dressings were removed. In a chemical burn model, application of silver-nylon or silver-calcium alginate dressings is associated with elevated wound levels but negligible tissue levels of silver ion.

Silver absorption and toxicity evaluation of silver wound dressings in 40 patients with chronic wounds

BACKGROUND

Silver-containing dressings are considered to be safe even though there have been some reports of complications, including argyria and various organ system dysfunctions. Despite the widespread use of silver dressings, little research has been done regarding the absorption and toxicity of silver.

OBJECTIVE

We aimed to study the systemic absorption of silver in patients with chronic inflammatory wounds and to determine associated factors of systemic silver absorption and evaluated its association with silver toxicity.

PATIENTS AND METHOD

Prospective, longitudinal, observational, multicentre, open-label pilot study. Patients from the Dermatology Departments of Lorraine (France) with the following inclusion criteria: (i) a chronic wound of more than 6 weeks and (ii) an ulcer needing silver-containing dressing were included. Before and after 28 days of treatment, clinical characteristics of the wound were recorded; hemogram, hepatic and renal functions, albumin sera and serum silver level were measured.

RESULTS

Half of the cases displayed raised levels of silver after 1 month of treatment. Predictive factors for systemic silver absorption were wound area, anaemia and malnutrition with anaemia and malnutrition confirmed on multivariate analysis. Wound vascularization may also play a role, as a higher absorption was observed in cases of wound granulation without arterial components. No toxicity was detected. This work has also emphasized the slow elimination of silver from the body.

CONCLUSION

Both long-term application and iterative treatments with silver dressings should be discouraged, especially in the elderly, who often suffer from malnutrition and anaemia to avoid potential cumulative toxicity.

A Case of Argyria and Acute Leukopenia Associated with the Use of an Antimicrobial Soft Silicone Foam Dressing

Silver has had an important role in preventing burn-related infections for decades. Relatively few side effects is one factor that has led to its wide spread use. Here, the authors present the first case of argyria, acute leukopenia, and possibly acute kidney injury associated with the use of a silver-containing soft silicone foam dressing. A 56-year-old female was transferred to the burn center with an exfoliating skin condition involving 70% TBSA diagnosed as toxic epidermal necrolysis associated with trimethoprim/sulfamethoxazole. On presentation she appeared to have clinical sepsis and was started on vancomycin and piperacillin/tazobactam. Clinical sepsis resolved within several days. Initial wound care consisted of daily topical double antibiotic and 3% bismuth tribromophenate petroleum gauze. After several days, the wounds were covered with a silver-containing soft silicone foam dressing. After 7 days, the leukocyte count declined from 18,000 to 600/cm. Silver toxicity was suspected and the dressings removed. Initial serum silver level was 190 and 249 μg/L 1 week later. The leukocyte level normalized within 7 days. Over the following days and weeks, the patient's skin began to show blue-gray coloration consistent with argyria. The patient subsequently developed acute kidney injury requiring hemodialysis and multiple organ failure. Although controversy exists about the causal relationship between silver-containing dressings and leukopenia, the authors believe that this case represents a case of acute leukopenia and argyria from the use of a silver-containing soft silicone foam dressing. It may have been a contributing factor to the development of acute kidney injury as well.

Inhibitory effect of silver nanoparticles on proliferation of estrogen-dependent MCF-7/BUS human breast cancer cells induced by butyl paraben or di-n-butyl phthalate

In this study the effect of silver nanoparticles (AgNPs) on proliferation of estrogen receptor (ER)-positive human breast cancer MCF-7/BUS cells was assessed by means of in vitro assay. The cells were exposed in the absence of estrogens to AgNPs alone or in combination with aluminum chloride (AlCl₃), butyl paraben (BPB) and di-n-butyl phthalate (DBPh). The results revealed that AgNPs at the non-cytotoxic concentrations (up to 2μg/mL) and AlCl₃ (up to 500μM) did not induce proliferation of MCF-7/BUS cells whereas BPB and DBPh showed strong estrogenic activity with the highest effect at 16μM and 35μM, respectively. AgNPs inhibited the proliferation of the cells induced by DBPh, BPB or even with 17β-estradiol (E2) during 6-day incubation in the absence of estrogens. ICI 182,780 (10nM), a known estrogen receptor (ER) antagonist, induced strong inhibitory effect. AgNPs also decreased transcription of the estrogen-responsive pS2 and progesterone receptor (PGR) genes but modulated expression neither of ERα nor ERβ in MCF-7/BUS cells exposed to BPB, DBPh or E2 for 6h. Our results indicate that AgNPs may inhibit growth of breast cancer cells stimulated by E2 or estrogenic chemicals, i.e. BPB and DBPh.

A study on the in vitro percutaneous absorption of silver nanoparticles in combination with aluminum chloride, methyl paraben or di-n-butyl phthalate

Some reports indicate that the silver released from dermally applied products containing silver nanoparticles (AgNP) (e.g. wound dressings or cosmetics) can penetrate the skin, particularly if damaged. AgNP were also shown to have cytotoxic and genotoxic activity. In the present study percutaneous absorption of AgNP of two different nominal sizes (Ag15nm or Ag45nm by STEM) and surface modification, i.e. citrate or PEG stabilized nanoparticles, in combination with cosmetic ingredients, i.e. aluminum chloride (AlCl₃), methyl paraben (MPB), or di-n-butyl phthalate (DBPH) was assessed using in vitro model based on dermatomed pig skin. The inductively coupled plasma mass spectrometry (ICP-MS) measurements after 24h in receptor fluid indicated low, but detectable silver absorption and no statistically significant differences in the penetration between the 4 types of AgNP studied at 47, 470 or 750μg/ml. Similarly, no significant differences were observed for silver penetration when the AgNP were used in combinations with AlCl₃ (500μM), MPB (1250μM) or DBPH (35μM). The measured highest amount of Ag that penetrated was 0.45ng/cm² (0.365-0.974ng/cm²) for PEG stabilized Ag15nm+MPB.

Ciprofloxacin-loaded keratin hydrogels reduce infection and support healing in a porcine partial-thickness thermal burn

Infection is a leading cause of morbidity and mortality in burn patients. Current therapies include silver-based creams and dressings, which display limited antimicrobial effectiveness and impair healing. The need exists for a topical, point-of-injury antibiotic treatment that provides sustained antimicrobial activity without impeding wound repair. Fitting this description are keratin-based hydrogels, which are fully biocompatible and support the slow-release of antibiotics. Here we develop a porcine model of an infected partial-thickness burn to test the effects of ciprofloxacin-loaded keratin hydrogels on infection and wound healing. Partial-thickness burns were inoculated with either Pseudomonas aeruginosa or Methicillin-resistant Staphylococcus aureus, resulting in infections that persisted for >2 weeks that exceeded 10(5) and 10(6) cfu per gram of tissue, respectively. Compared to silver sulfadiazine, ciprofloxacin-loaded keratin hydrogel treatment significantly reduced the amount of P. aeruginosa and S. aureus in the burn by >99% on days 4, 7, 11, and 15 postinjury. Further, burns treated with ciprofloxacin-loaded keratin hydrogels exhibited similar healing patterns as uninfected burns with regards to reepithelialization, macrophage recruitment, and collagen deposition and remodeling. The ability of keratin hydrogels to deliver antibiotics to fight infection and support healing of partial-thickness burns make them a strong candidate as a first-line burn therapy.

Silver from polyurethane dressing is delivered by gradient to exudate, tissue, and serum of patients undergoing negative-pressure wound treatment

OBJECTIVE

This study aimed to evaluate the distribution and concentration of silver eluted from silver-coated polyurethane dressing (V.A.C. GranuFoam Silver Dressing; KCI, San Antonio, Texas) in vitro and in patients undergoing negative-pressure wound therapy (NPWT).

DESIGN

This was a descriptive study of the effect of silver-coated polyurethane dressing in patients undergoing NPWT.

PARTICIPANTS

Six patients with infected wounds undergoing NPWT using silver-coated polyurethane dressing.

INTERVENTIONS

To evaluate silver release in vitro, the authors soaked dressing fragments in water and human serum for different lengths of time and performed atomic absorption spectroscopy. For patient evaluation, the authors obtained exudate, serum, and wound tissue at different time points from 6 patients undergoing NPWT and measured silver levels by atomic absorption and dispersed x-ray spectroscopy.

MAIN RESULTS

Silver from the dressing was immediately released in vitro at a rate 3 times greater in serum than in water. In vivo, silver was delivered to wound exudate at rates 102 to 104 times greater than in corresponding serum. Few surface silver deposits were detected in treated tissue.

CONCLUSION

The high concentration of silver found in wound exudate reflects not only the affinity for silver in serum components and wound fluids, but also that most silver ions are not distributed systemically in the patient; instead, they are transported by the vacuum created by therapy.

Dressings and Products in Pediatric Wound Care

Significance: The increasing complexity of medical and surgical care provided to pediatric patients has resulted in a population at significant risk for complications such as pressure ulcers, nonhealing surgical wounds, and moisture-associated skin damage. Wound care practices for neonatal and pediatric patients, including the choice of specific dressings or other wound care products, are currently based on a combination of provider experience and preference and a small number of published clinical guidelines based on expert opinion; rigorous evidence-based clinical guidelines for wound management in these populations is lacking. Recent Advances: Advances in the understanding of the pathophysiology of wound healing have contributed to an ever-increasing number of specialized wound care products, most of which are predominantly marketed to adult patients and that have not been evaluated for safety and efficacy in the neonatal and pediatric populations. This review aims to discuss the available data on the use of both more traditional wound care products and newer wound care technologies in these populations, including medical-grade honey, nanocrystalline silver, and soft silicone-based adhesive technology. Critical Issues: Evidence-based wound care practices and demonstration of the safety, efficacy, and appropriate utilization of available wound care dressings and products in the neonatal and pediatric populations should be established to address specific concerns regarding wound management in these populations. Future Directions: The creation and implementation of evidence-based guidelines for the treatment of common wounds in the neonatal and pediatric populations is essential. In addition to an evaluation of currently marketed wound care dressings and products used in the adult population, newer wound care technologies should also be evaluated for use in neonates and children. In addition, further investigation of the specific pathophysiology of wound healing in neonates and children is indicated to promote the development of wound care dressings and products with specific applications in these populations.

The biological fate of silver ions following the use of silver-containing wound care products - a review

Ionic silver has a long history as an antimicrobial in human health care. This article is a review of the published literature on how ionic silver may enter the body from exposure to silver-containing wound care products and its eventual metabolic fates, in an assessment of the safety during normal use of these products in wound care. Following the application to breached skin, there appears to be little evidence of localised or systemic toxicity, and this is borne out by the continuous use of silver sulfadiazine formulations for more than 50 years. Consequently, following normal use, the risk of silver ion toxicity locally and systemically is considered to be low or negligible.

PHMB: an effective antimicrobial in wound bioburden management

The effective management of bacterial bioburden is an essential element of wound care. Recent years have seen the increased use of topical antimicrobial dressings to control colonisation and infection, yet there is concern that some may inhibit wound healing and may have systemic sequelae (World Union of Wound Healing Societies (WUWHS), 2008). This article focuses on the safety and effectiveness of PHMB, an antimicrobial compound that is relatively underused in the UK, and argues that it is an effective option for the management of bacterial colonisation and infection.

The correlation of in vivo burn scar contraction with the level of α-smooth muscle actin expression

This study describes the direct association of in vivo burn scar contraction with the level of α-smooth muscle actin (α-SMA) in scar tissue, in a porcine burn model. The expression of α-SMA was investigated in 100 biopsies from 44 6-week old burn scars and in 85 biopsies from 16 2-week old burn wounds. Statistical analysis showed that the levels of α-SMA in 6-week old scars were significantly negatively correlated to scar size (r=-0.68) and the higher levels of α-SMA were observed in smaller scars. Moreover, α-SMA was also found to be significantly positively correlated to re-epithelialisation time (r=0.57) and scar thickness (r=0.58) and higher levels of α-SMA were detected in thicker scars with delayed wound closure. Further statistical analysis revealed that scar contraction can be explained best by the level of α-SMA expression and partially by scar thickness. Other variables, such as different dressings and individual pig, may also partly contribute to scar contraction. At week 2 after-burn, the level of α-SMA expression in 16 burn wounds was significantly related to the depth of burns and wound healing outcome. To our knowledge, this is the first study to provide in vivo evidence of the association of α-SMA expression with scar contraction, scar thickness, re-epithelialisation time and the depth of burn in a large animal burn model with scars similar to human hypertrophic scar.

Osteoconductivity of thermal-sprayed silver-containing hydroxyapatite coating in the rat tibia

A silver-containing hydroxyapatite (Ag-HA) coating has been developed using thermal spraying technology. We evaluated the osteoconductivity of this coating on titanium (Ti) implants in rat tibiae in relation to bacterial infection in joint replacement.

At 12 weeks, the mean affinity indices of bone formation of a Ti, an HA, a 3%Ag-HA and a 50%Ag-HA coating were 97.3%, 84.9%, 81.0% and 40.5%, respectively. The mean affinity indices of bone contact of these four coatings were 18.8%, 83.7%, 77.2% and 40.5%, respectively. The indices of bone formation and bone contact around the implant of the 3%Ag-HA coating were similar to those of the HA coating, and no significant differences were found between them (bone formation, p = 0.99; bone contact, p = 0.957). However, inhibition of bone formation was observed with the 50%Ag-HA coating.

These results indicate that the 3%Ag-HA coating has low toxicity and good osteoconductivity, and that the effect of silver toxicity on osteoconductivity depends on the dose.

Conservative management of exomphalos major with silver dressings: are they safe?

Historically, some dressings used in exomphalos major were associated with toxicity. These have been abandoned in favor of safer dressings. Silver toxicity has not been described following the use of silver dressings in infants. We, however, found disconcerting serum silver levels in 2 consecutive patients during treatment with silver salt containing dressings.